Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 44

The most common cause of hemoptysis worldwide: a fluke? Amritpal Nat, MD, Amitpal Nat, MD, Amit Sharma, MBBS, MPH, Ghanshyam Shastri, MD, and Michael C. Iannuzzi, MD, MBA Global travel is associated with an increasing incidence of helminthic infections in nonendemic regions. We describe a patient with recurrent hemoptysis from a chronic infection not commonly found in the USA. CASE PRESENTATION A 20-year-old healthy female college swimmer was referred for evaluation of intermittent episodes of hemoptysis for 1 year. She had one to two episodes every other week of quarter-sized hemoptysis associated with dyspnea. Her symptoms began after a dive 3 meters above the pool resulting in a “belly flop.” Her vital signs and complete blood count with differential we re within normal limits, and her initial radiograph was normal. Computed tomography (CT) showed two cystic lesions in the right lower lobe (Figure 1). The patient denied alcohol, cigarette, or illicit drug use. She had traveled to Costa Rica and the Bahamas 1 year earlier. Bronchoscopy with bronchoalveolar lavage, brushings, and CT-guided biopsy were unremarkable. Cultures from the bronchial washings and the cytology were negative. Pulmonary function tests were normal. Workup for connective tissue disorders was negative. Further evaluation for pulmonary tuberculosis, mycoplasma, histoplasmosis, and blastomycosis was negative. Subsequent CT scans showed interval resolution and redistribution of the cystic lesions (Figure 2). Paragonimus westermani antibody titers were obtained 1 year after the initial presentation and were elevated at 1:32. The diagnosis of chronic pulmonary paragonimiasis was made, and the patient responded well to praziquantel (1, 2). DISCUSSION The presentation of hemoptysis after diving with the finding of cysts on chest CT led to a consideration of traumatic pneumatocele. Given the relatively mild chest injury at the time of the dive, the resolution and recurrence of the lung parenchymal cysts, and the recent travel history, an infectious etiology was more likely. Although stool, sputum, and bronchial washings for ova and parasites 118 Figure 1. CT thorax showing thin-walled cysts within the parenchyma of the right lower lobe. This represents a late radiologic finding of pulmonary paragonimiasis. were negative, Paragonimus westermani titers were elevated. Serologic testing for anti-Paragonimus IgG has a sensitivity of nearly 100% and a specificity of 91% to 100% (3). Paragonimus westermani, also known as the lung fluke, is acquired through the ingestion of raw/undercooked crabs or crayfish. It is the most common cause of hemoptysis worldwide (4). Diagnosis can be challenging, and clinicians should be alerted to the sensitivity and specificity of serologic testing. Treatment involves a 3-day course of praziquantel with a response rate of 100% (5). This clinical vignette underscores the importance of health care providers in the USA recognizing common worldwide infections. From State University of New York Upstate Medical University, Syracuse, New York. Corresponding author: Amritpal Nat, MD, State University of New York Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210-2375 (e-mail: [email protected]). Proc (Bayl Univ Med Cent) 2014;27(2):118–119